Florida Senate - 2013                                     SB 896
       By Senator Garcia
       38-01015-13                                            2013896__
    1                        A bill to be entitled                      
    2         An act relating to prepaid dental plans; amending s.
    3         409.912, F.S.; postponing the scheduled repeal of a
    4         provision requiring the Agency for Health Care
    5         Administration to contract with dental plans for
    6         dental services on a prepaid or fixed-sum basis;
    7         authorizing the agency to provide a prepaid dental
    8         health program in Miami-Dade County on a permanent
    9         basis; providing an effective date.
   11  Be It Enacted by the Legislature of the State of Florida:
   13         Section 1. Subsection (41) of section 409.912, Florida
   14  Statutes, is amended to read:
   15         409.912 Cost-effective purchasing of health care.—The
   16  agency shall purchase goods and services for Medicaid recipients
   17  in the most cost-effective manner consistent with the delivery
   18  of quality medical care. To ensure that medical services are
   19  effectively utilized, the agency may, in any case, require a
   20  confirmation or second physician’s opinion of the correct
   21  diagnosis for purposes of authorizing future services under the
   22  Medicaid program. This section does not restrict access to
   23  emergency services or poststabilization care services as defined
   24  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   25  shall be rendered in a manner approved by the agency. The agency
   26  shall maximize the use of prepaid per capita and prepaid
   27  aggregate fixed-sum basis services when appropriate and other
   28  alternative service delivery and reimbursement methodologies,
   29  including competitive bidding pursuant to s. 287.057, designed
   30  to facilitate the cost-effective purchase of a case-managed
   31  continuum of care. The agency shall also require providers to
   32  minimize the exposure of recipients to the need for acute
   33  inpatient, custodial, and other institutional care and the
   34  inappropriate or unnecessary use of high-cost services. The
   35  agency shall contract with a vendor to monitor and evaluate the
   36  clinical practice patterns of providers in order to identify
   37  trends that are outside the normal practice patterns of a
   38  provider’s professional peers or the national guidelines of a
   39  provider’s professional association. The vendor must be able to
   40  provide information and counseling to a provider whose practice
   41  patterns are outside the norms, in consultation with the agency,
   42  to improve patient care and reduce inappropriate utilization.
   43  The agency may mandate prior authorization, drug therapy
   44  management, or disease management participation for certain
   45  populations of Medicaid beneficiaries, certain drug classes, or
   46  particular drugs to prevent fraud, abuse, overuse, and possible
   47  dangerous drug interactions. The Pharmaceutical and Therapeutics
   48  Committee shall make recommendations to the agency on drugs for
   49  which prior authorization is required. The agency shall inform
   50  the Pharmaceutical and Therapeutics Committee of its decisions
   51  regarding drugs subject to prior authorization. The agency is
   52  authorized to limit the entities it contracts with or enrolls as
   53  Medicaid providers by developing a provider network through
   54  provider credentialing. The agency may competitively bid single
   55  source-provider contracts if procurement of goods or services
   56  results in demonstrated cost savings to the state without
   57  limiting access to care. The agency may limit its network based
   58  on the assessment of beneficiary access to care, provider
   59  availability, provider quality standards, time and distance
   60  standards for access to care, the cultural competence of the
   61  provider network, demographic characteristics of Medicaid
   62  beneficiaries, practice and provider-to-beneficiary standards,
   63  appointment wait times, beneficiary use of services, provider
   64  turnover, provider profiling, provider licensure history,
   65  previous program integrity investigations and findings, peer
   66  review, provider Medicaid policy and billing compliance records,
   67  clinical and medical record audits, and other factors. Providers
   68  are not entitled to enrollment in the Medicaid provider network.
   69  The agency shall determine instances in which allowing Medicaid
   70  beneficiaries to purchase durable medical equipment and other
   71  goods is less expensive to the Medicaid program than long-term
   72  rental of the equipment or goods. The agency may establish rules
   73  to facilitate purchases in lieu of long-term rentals in order to
   74  protect against fraud and abuse in the Medicaid program as
   75  defined in s. 409.913. The agency may seek federal waivers
   76  necessary to administer these policies.
   77         (41)(a) The agency shall contract on a prepaid or fixed-sum
   78  basis with appropriately licensed prepaid dental health plans to
   79  provide dental services. This paragraph expires October 1, 2017
   80  2014.
   81         (b) Notwithstanding paragraph (a) and for the 2012-2013
   82  fiscal year only, the agency may is authorized to provide a
   83  Medicaid prepaid dental health program in Miami-Dade County. For
   84  all other counties, the agency may not limit dental services to
   85  prepaid plans and must allow qualified dental providers to
   86  provide dental services under Medicaid on a fee-for-service
   87  reimbursement methodology. The agency may seek any necessary
   88  revisions or amendments to the state plan or federal waivers in
   89  order to implement this paragraph. The agency shall terminate
   90  existing contracts as needed to implement this paragraph. This
   91  paragraph expires July 1, 2013.
   92         Section 2. This act shall take effect June 30, 2013.